Provider Demographics
NPI:1376830281
Name:MALCOM, ALEXIS WHITTAKER (NP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:WHITTAKER
Last Name:MALCOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 PAINE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05663-5791
Mailing Address - Country:US
Mailing Address - Phone:781-413-4985
Mailing Address - Fax:
Practice Address - Street 1:45 PALMER ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1834
Practice Address - Country:US
Practice Address - Phone:978-970-1607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0134327363L00000X
MARN2262711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily